Provider Demographics
NPI:1003943937
Name:KELLEY, MARY LOU (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7936 WRENWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-7701
Mailing Address - Country:US
Mailing Address - Phone:225-925-2036
Mailing Address - Fax:
Practice Address - Street 1:7936 WRENWOOD BLVD STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-7701
Practice Address - Country:US
Practice Address - Phone:225-925-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical